What is the cause of the problem?

The identification and selection of appropriate options for addressing a problem should be guided by an understanding of its cause. Such insights may also lead to the original framing choice being changed. Often the causes of health systems problems are complex and uncertain and it may be more appropriate to consider underlying factors without attributing causation. The process of clarifying the cause or underlying factors is unlikely to be simple or linear. And although it may be possible to reduce uncertainty about the cause, it may be equally or more important to clarify uncertainty about the cause. Strategies for clarifying the cause of health system problems include using either broader or more specific frameworks, brainstorming, reviewing relevant research evidence, and interviews with key informants.

Broad frameworks for health system problems that could be used include the extent to which the problem is due to delivery, financial and governance arrangements (see Table 3.2),^3,4 or to the implementation of existing policies (see SURE Guide 5. Identifying and addressing barriers to implementing the options). Although, for example, the problem may be described initially as a problem with delivery arrangements (e.g. a shortage of health workers in rural areas), the cause of this shortage instead may actually have to do with financial arrangements (e.g. how health workers are remunerated) or governance arrangements (e.g. the licensing of different types of health workers to perform specific tasks).

More specific frameworks may facilitate a more detailed consideration of the potential causes of some types of problems. For example, a framework for addressing problems with human resources for health might be used to think systematically through the potential causes of problems such as a shortage of health workers, their distribution, their performance, or their cost and efficient use, and to consider the solutions to these.⁵ Similarly, a framework for healthcare financing may help with thinking through the problems with health care financing systematically (Figure 1).⁶ Other examples of frameworks are shown in Table 3.3. Searching for frameworks such as these can be done easily using Google Scholar or PubMed by combining the word ‘framework’ with key words describing the problem. Often the most efficient way of finding frameworks is to talk to people with expertise in the specific area of interest. Other sources of such frameworks include other policy briefs on the same or closely related issues, policy analyses, and systematic reviews or overviews of systematic reviews.

Figure 1. Framework for health system financing functions (from Kutzin 2001)⁶

Table 3.3 Examples of frameworks for analysing the cause of a problem or underlying factors
Problem	Framework	Reference
Illegal sale of pharmaceuticals	Conceptual framework for understanding determinants of market outcomes and normative consequences of public health product sales	Conteh L, Hanson K. Methods for studying private sector supply of public health products in developing countries: a conceptual framework and review. Social Science and Medicine 2003; 57:1147-61.
Integration of TB and HIV services	Analytic framework for vertical versus horizontal approaches for delivering priority health services	Oliveira-Cruz V, Kurowski C, Mills A. Delivery of priority health Services: searching for synergies within the vertical versus horizontal debate. J International Development 2003; 15:67-86.
Community health worker performance	Analytical framework for productivity, competence and responsiveness	Dieleman M, Harnmeijer JW. Improving health worker performance: in search of promising practices. Evidence and Information for Policy, Department of Human Resources for Health, WHO: Geneva, 2006.
Underutilisation of antenatal care	Factors affecting the utilisation of antenatal care	Simkhada B, van Teijlingen ER, Porter M, Simkhada P. Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. J Advanced Nursing 2008; 61:244–60.
Skilled birth attendance	Strategies for increasing demand and bringing pregnant women closer to the formal health system	Lee ACC, Lawn JE, Cousens S, et al. Linking families and facilities for care at birth: What works to avert intrapartum-related deaths? International J Gyn Obs 2009; 107: S65–S88
Health insurance coverage	Strategies for expanding coverage of health insurance schemes	Meng Q, Yuan B, Jia L, et al. Expanding health insurance coverage in vulnerable groups: a systematic review of options. Health Policy Planning 2010; 1–12.

Brainstorming and creative thinking can also be helpful and can be done either in a structured way using a framework, or in an unstructured way. It is desirable too that people with different perspectives are involved as well as those with a broad knowledge of the health system. Doing this may be an iterative process. It may start with hypotheses about the potential causes of the problem, followed by searches for information to support or refute those hypothese, then a discussion about the causes of the problem based on the information found.

Information to support or refute hypotheses can come from:

Routine Health Information Systems
Studies that have been undertaken within the country (e.g. of the perceptions and attitudes of patients or health workers)
Studies that have been undertaken internationally or in other settings with similar problems
Key informants (i.e. by interviewing or discussing the problem with individuals with relevant experience or knowledge)

What is the cause of the problem?

Table 3.3 Examples of frameworks for analysing the cause of a problem or underlying factors

This page was last updated November 2011.